Mental skills training effectively minimizes operative performance deterioration under stressful conditions: Results of a randomized controlled study

Background

Stress can negatively impact surgical performance, but mental skills may help. We hypothesized that a comprehensive mental skills curriculum (MSC) would minimize resident performance deterioration under stress.

Assessment of stress and teamwork in the operating room: an exploratory study

Background

Although effective teamwork is fundamental to patient safety in the operating room (OR), acute stress increasingly is recognized as detrimental for teamwork. This study concurrently assessed teamwork and stress levels experienced by OR team members.

Methods

Data were collected in real time in 20 elective surgical cases. The validated Observational Teamwork Assessment for Surgery was used to assess teamwork, whereas stress was assessed using the validated State-Trait Anxiety Inventory.

Results

Teamwork was overall above the scale midpoint, with higher scores preoperatively than in subsequent phases of the procedure, and also higher ratings for anesthetic subteams compared with surgical and nursing subteams (all P < .01). Overall stress levels were low. Qualitative analyses revealed differences across team members: circulating staff preoperatively and assistant surgeons intraoperatively and postoperatively were most likely to be stressed.

Conclusions

The study offers a feasible method for concurrently assessing stress and teamwork in the OR and reveals differences across team members' stress levels as surgery unfolds. This methodology can be used to increase understanding of the impact of stress on team performance in the OR.     

Fall-related self-efficacy, not balance and mobility performance, is related to accidental falls in chronic stroke survivors with low bone mineral density

SUMMARY: Chronic stroke survivors with low hip bone density are particularly prone to fractures. This study shows that fear of falling is independently associated with falls in this population. Thus, fear of falling should not be overlooked in the prevention of fragility fractures in these patients. INTRODUCTION: Chronic stroke survivors with low bone mineral density (BMD) are particularly prone to fragility fractures. The purpose of this study was to identify the determinants of balance, mobility and falls in this sub-group of stroke patients. METHODS: Thirty-nine chronic stroke survivors with low hip BMD (T-score <-1.0) were studied. Each subject was evaluated for the following: balance, mobility, leg muscle strength, spasticity, and fall-related self-efficacy. Any falls in the past 12 months were also recorded. Multiple regression analysis was used to identify the determinants of balance and mobility performance, whereas logistic regression was used to identify the determinants of falls. RESULTS: Multiple regression analysis revealed that after adjusting for basic demographics, fall-related self-efficacy remained independently associated with balance/mobility performance (R2 = 0.494, P < 0.001). Logistic regression showed that fall-related self-efficacy, but not balance and mobility performance, was a significant determinant of falls (odds ratio: 0.18, P = 0.04). CONCLUSIONS: Fall-related self-efficacy, but not mobility and balance performance, was the most important determinant of accidental falls. This psychological factor should not be overlooked in the prevention of fragility fractures among chronic stroke survivors with low hip BMD.     

The age distribution, rates, and types of surgery for stress urinary incontinence in the USA

The objective of this study was to describe the distribution of stress urinary incontinence (SUI) surgery across age groups in the USA in 2003. Patients were grouped into four age categories: reproductive, perimenopausal, postmenopausal, and elderly. Data from the 2003 National Hospital Discharge Survey and National Census were used to estimate surgical rates by age group. In 2003, 129,778 women underwent 165,776 surgical procedures for SUI. Of these women, 12.2, 53.0, 30.4, and 4.5% belonged to reproductive, perimenopausal, postmenopausal, and elderly age groups, respectively. Surgical rates (per 10,000 women) were 4, 17, 19, and 9 in these age groups, respectively. Complications occurred most frequently in reproductive age women. Overall, SUI surgical rates were similar for perimenopausal and postmenopausal women and exceeded that in the elderly population. The greatest percentage of surgical procedures occurred in perimenopausal women. Women at all stages of reproductive life may seek surgical treatment for SUI. This paper was presented at the annual meeting of the American Urogynecologic Society, Palm Springs, CA, October 19–21, 2006.     

Use of physiologic monitoring to predict outcome and to assist in clinical decisions in critically ill postoperative patients

A predictive index based on cardiorespiratory-monitored values of an earlier series of postoperative critically ill patients was tested in prospective clinical trials and found to be reasonably accurate, sensitive, and specific. The hypothesis was tested that the median values of patients who survived life-threatening postoperative conditions, rather than the norms of unstressed, healthy volunteer subjects, constitute a first approximation to the optimal therapeutic goals for critically ill postoperative patients. In a prospective series of 223 consecutive, critically ill postoperative patients, normal values were used as the therapeutic goals of the control patients, whereas the median values of surviving patients were used as the goals of therapy for the protocol group. The clinical conditions of the protocol group were at least as severe as those of the control group, but the mortality was significantly less in the protocol group (12.5 percent) than in the control group (35 percent); the number of life-threatening complications were also greater in the control group. These data suggest that at least half and possibly as much as two thirds of postoperative deaths may be due to physiologic problems that can be identified, described, predicted, and prevented. Therapy for the critically ill patient should be defined by physiologic criteria, and administration of therapy should be monitored to attain prophylactically optimal physiologic goals rather than giving therapy after a deficiency has occurred to attain normal values.     

Surgical training in the 48-h week: a novel simulation and educational tool. From amateur golfer to professional pilot

Introduction: Compliance with the European Working Time Directive has made obvious the need for a surgical skills training system that will produce surgeons fast and reliably. We have previously proposed a model for objective assessment of surgical dexterity. In this paper we aim to place an updated version of that model into the context of a holistic approach on assessment of a trainee's progress towards becoming an independently operating surgeon. Methods: The PAR matrix breaks down an operation into clearly defined skills that need to be successively acquired. It consists of a 3 × 6 table depicting 18 skill-goals. The y-axis is divided into six levels and the x-axis into three columns. The initials of the three skills on each level form the acronym PAR. Each skill is further graded from 1 to 3 (unsatisfactory, competent, good). The levels are: Level 1 – posture, address, relaxation; Level 2 – pick-up, airtime, rotation; Level 3 – placing, angles, rhythm; Level 4 – precision, adaptability, reproducibility; Level 5 – pace, awareness, relations; Level 6 – planning, announce, review/reflexion. Results: The format of the PAR model is such that it allows trainer and trainee to objectively assess progress, identify deficiencies and strengths and formulate an appropriate plan of action. Conclusion: Ergonomics and crew resource management skills are essential for a safe operating environment. The PAR matrix may prove helpful in selection of trainees and revalidation of trainee surgeons as a competence and performance testing method, placed in the appropriate training curriculum.     

Adaptation and validation of the SEGUE checklist to assess osteopathy students' clinical communication skills

ObjectiveThis paper explores the adaptation and validation of the SEGUE checklist as a tool to assess clinical communication skills in undergraduate osteopathy students in Australia.MethodsA literature review guided instrument selection of the SEGUE tool for the learning, teaching and assessment of clinical communication skills in undergraduate osteopathy students. The SEGUE framework checklist was modified and adapted to meet the practises of undergraduate osteopathy students and a subsequent study was conducted to assess its validity; intra-rater and inter-rater reliability over three time points.ResultsA modified SEGUE checklist was developed and validated. Statistical analysis revealed acceptable inter-rater reliability at two time points six weeks apart. Intra-rater reliability revealed moderate to good reliability between the two time points six weeks apart. Testing also revealed scope for further sub-element refinement.ConclusionThe SEGUE checklist has the potential to be suitably adapted for both teaching and assessing clinical communication skills in undergraduate osteopathy students. Further work across a number of universities is needed to add and refine sub-elements of the checklist.     

A randomised controlled trial comparing two autologous fascial sling techniques for the treatment of stress urinary incontinence in women: short, medium and long-term follow-up

This randomised control trial compares full-length autologous slings (Group A: 81 women) with a modified “sling-on-a-string” (Group B: 84 women) technique for the treatment of stress urinary incontinence (SUI). Primary outcomes are quality of life (QoL) scores; Group A/Group B. The IIQ-7 scores decrease from 1.91/1.85 at baseline to 0.65/0.72 at 12 months and 0.85/0.92 at +5 years. The UDI-6 scores decrease from 1.85/1.61 at baseline to 0.66/0.62 at 12 months and 1.22/1.08 at +5 years. The incidence of SUI is 13% at 3 months but averages 53% at +5 years. Both techniques offer similar improvements. The shorter sling is quicker, less painful and with less hospital readmissions. The ‘sling-on-a-string’ technique is as effective as the standard technique with better short-term sequelae. The incidence of SUI post-autologous slings rises over the long term.     

Comparison of transcutaneous oximetry, vascular hemodynamic measurements, angiography, and clinical findings to predict the success of peripheral vascular reconstruction

The present study examined prospectively the prognostic value of preoperative clinical findings, angiography, and conventional vascular hemodynamic and transcutaneous oximetry measurements in a consecutive series of patients undergoing lower extremity vascular reconstruction. A total of 25 variables were independently evaluated in each limb. Follow-up at least 6 months after operation was carried out in all patients. The postocclusive transcutaneous oxygen recovery time was found to be the most accurate predictor of short-term femoropopliteal bypass graft success. Preoperative foot transcutaneous oxygen recovery time values were significantly worse in patients whose femoropopliteal bypass grafts failed than in those in whom the outcome was successful (p less than 0.03). Transcutaneous oxygen recovery time values were also valuable in patients who underwent aortofemoral bypass; patients with isolated aortoiliac disease had significantly better foot transcutaneous oxygen recovery time values than those with combined aortoiliac and femoropopliteal disease (p less than 0.05). Foot transcutaneous oxygen recovery time values were also found to correlate well with the severity of symptoms (p less than 0.01), as did ankle-brachial Doppler pressure indices. Although the other variables analyzed provided useful diagnostic information, none were as accurate as the postocclusive transcutaneous oxygen recovery time in predicting the outcome of peripheral vascular reconstruction. As a means of more accurately classifying patients with peripheral vascular disease, we recommend the complimentary use of clinical findings, angiography, and hemodynamic and transcutaneous oximetry measurements. Because transcutaneous oxygen tension reflects the balance between local oxygen supply and demand, it may help to better define risk factors preoperatively in physiologic terms.     

Solitary fibrous tumors of the pleura: clinical characteristics, surgical treatment and outcome

Objective: The aim of this paper is to study clinical characteristics, surgical treatment and outcome of patients with solitary fibrous tumor of the pleura operated in our institutions in a 20-year period. Methods: Clinical records of all patients operated for solitary fibrous tumors of the pleura between 1981 and 2000 were reviewed retrospectively. Tumors were classified as malignant in the presence of at least one of the following criteria: (1) high mitotic activity; (2) high cellularity with crowding and overlapping of nuclei; (3) presence of necrosis; (4) pleomorphism; otherwise they were considered as benign. Results: Sixty patients (mean age 55 years) were operated in this period. None had asbestos exposure. Symptoms were present in 31 cases. Surgical approaches included thoracotomy (n=53), video-assisted thoracoscopy (n=6), and median sternotomy (n=1). Tumors originated from visceral pleura in 48 cases, from parietal, mediastinal or diaphragmatic pleura in seven, two and three cases, respectively; their mean diameter was 8.5 cm. Tumors could be resected with their implantation basis in 49 patients. In the remaining 11, extended resections were performed, including lung parenchyma (lobectomy, n=4, pneumonectomy, n=2), osteomuscular chest wall structures (n=2), diaphragm (n=2), and pericardium (n=1). Two postoperative deaths (due to myocardial infarction and pulmonary embolism, respectively) occurred. Tumors were pathologically benign in 38 cases and malignant in 22 cases. Mean follow-up was 88 months. Resection was complete in all the patients with benign tumors and no recurrence occurred. Resection was considered as complete in 21/22 malignant tumors. Local recurrence was observed in two cases. Both could be successfully managed by iterative exeresis (no extended resection had been initially performed). Metastatic disease (responsible for patient's death) was observed following the only incomplete resection. Actuarial 5- and 10-year survival rates were 97% for benign tumors and 89% for malignant ones. Conclusions: Surgical resection provided cure in all the patients with benign tumors. As insufficiency of exeresis is associated with all recurrences in malignant tumors, completeness of resection is in our experience the best prognostic factor in these forms.     

Contributions from surgeons to clinical trials and research on the management of soft tissue sarcoma

Background: Surgical resection is the primary treatment for soft tissue sarcoma. Surgeons are in a position to develop and define appropriate treatment strategies for this disease. In an effort to define the contributions of surgeons to the management of sarcoma, the surgical and clinical oncology literature from January 1983 through June 1996 was reviewed. Methods: A computerized literature search of the Cancerlit database for January 1983 to June 1996 was performed. The search was limited to the topic of soft tissue sarcoma and was further confined to 15 journals that publish articles relevant to surgical management. These studies were then categorized by multiple parameters and analyzed. Results: The Cancerlit file contained 4478 articles in which sarcoma was the primary topic. When the search was limited to 15 journals frequently read by surgeons, 479 references (11%) were retrieved. Within the surgical literature, 95 of the 479 articles (20%) described prospective studies, of which 33 were prospective and randomized. These studies represent all but three of the prospective randomized trials within the literature during the time period reviewed. The management of patients with sarcoma was evaluated in 26 of the prospective randomized trials; of these, 13 trials evaluated adjuvant chemotherapy, three evaluated adjuvant radiotherapy, and ten evaluated the chemotherapeutic treatment of metastatic disease. Surgical oncologists were the first or senior author on 10 of the 16 prospective randomized studies regarding adjuvant radiation or chemotherapy. Four of the 16 trials evaluating adjuvant therapy contained more than 100 patients, and three of those four were from cooperative group efforts. All but one of the studies of adjuvant therapy with less than 100 patients were from single institutional trials. Conclusions: Although the surgical and clinical oncology literature on soft tissue sarcoma is composed primarily of retrospective reviews, the prospective randomized trials reported represent almost all of the randomized trials in the literature and have significant contributions from surgeons. Surgeons can guide and design clinical trials, but overall patient accrual as represented by soft tissue sarcoma is low, and may be improved through cooperative group efforts.The opinions contained herein do not necessarily reflect the opinions of the Department of the Army or the Department of Defense.     

Comparison of learning curves and skill transfer between classical and robotic laparoscopy according to the viewing conditions: implications for training

BACKGROUND: The purpose of this study was to evaluate the perceptual (2-dimensional [2D] vs. 3-dimensional [3D] view) and instrumental (classical vs. robotic) impacts of new robotic system on learning curves. METHODS: Forty medical students without any surgical experience were randomized into 4 groups (classical laparoscopy with 3D-direct view or with 2D-indirect view, robotic system in 3D or in 2D) and repeated a laparoscopic task 6 times. After these 6 repetitions, they performed 2 trials with the same technique but in the other viewing condition (perceptive switch). Finally, subjects performed the last 3 trials with the technique they never used (technical switch). Subjects evaluated their performance answering a questionnaire (impressions of mastery, familiarity, satisfaction, self-confidence, and difficulty). RESULTS: Our study showed better performance and improvement in 3D view than in 2D view whatever the instrumental aspect. Participants reported less mastery, familiarity, and self-confidence and more difficulty in classical laparoscopy with 2D-indirect view than in the other conditions. CONCLUSIONS: Robotic surgery improves surgical performance and learning, particularly by 3D view advantage. However, perceptive and technical switches emphasize the need to adapt and pursue training also with traditional technology to prevent risks in conversion procedure.     

进展期胰头癌扩大根治术的临床研究疗效现状和前景

进展期胰头癌扩大根治术后加综合治疗使5年生存率明显提高,并发症明显减少.进展期胰头癌扩大根治术中加改良Whipple术式及TACE临床研究在近远期生活质量上有明显改善,但这毕竟是有益的探索,是向外科手术治疗胰头癌顽症迈进一步,具有临床应用价值.综述国内外近年来进展期胰头癌外科治疗的方法及疗效现状.探讨进展期胰头癌扩大根治术的临床研究疗效前景.     

Waterjet dissection in the brain: review of the experimental and clinical data with special reference to meningioma surgery

Waterjet dissection enables precise parenchymal dissection under preservation of vessels and reduction of intraoperative blood loss in general surgery. The present study reports our experimental and clinical results with this device in neurosurgery. Our experimental studies in the porcine cadaver brain show that the device allows very accurate, precise, and reliable dissection of the brain. A linear relationship between waterjet pressure and dissection depth was demonstrated. Vessel preservation was observed at pressures below 20 bar. Clinically, precise dissection of brain parenchyma and various tumors was performed without complications. Even in meningiomas, with their very variable firmness, vascularization, and adherence to the surrounding brain, accurate dissection could be achieved. However, while tumor separation from the brain was attained with high accuracy and vessel preservation in all cases, only in softer lesions resection by aspiration under vessel preservation was possible with pressures below 20 bar. In all, the waterjet device enables precise tissue dissection and vessel preservation in various pathologies including meningiomas. It could represent an addition to the neurosurgical armamentarium. Further studies will have to show dissection qualities of this device that are superior to conventional methods.     

Trends in the clinical presentation,treatment, and survival for pancreatic adenocarcinoma

Background

We assessed trends in the clinical presentation, treatment, and survival for pancreatic adenocarcinoma.

The Adult Deformity Surgery Complexity Index (ADSCI): a valid tool to quantify the complexity of posterior adult spinal deformity surgery and predict postoperative complications

Background Context

In 2008, Mirza et al. designed and validated the first and only index capable of quantifying the complexity of spine surgery. However, this index is not fully applicable to adult spinal deformity (ASD) surgery as it does not include the surgical techniques most commonly used and most strongly associated with perioperative complications in patients with ASD.

Osteocalcin and the hormonal, inflammatory and metabolic response to major orthopaedic surgery

Plasma osteocalcin, a marker of osteoblastic activity, decreases after major abdominal and gynaecological surgery. Increased cortisol secretion and other hormonal and inflammatory components of the peri-operative stress response may play a role in mediating this response. We assessed the effects of three different anaesthetic techniques on peri-operative osteocalcin concentrations. Thirty-six female patients undergoing elective total hip replacement were randomly assigned to receive propofol, propofol plus 'three-in-one' block or etomidate as part of a general anaesthetic technique. We measured plasma osteocalcin and serum cortisol, bone specific alkaline phosphatase, interleukin-6, plasma epinephrine, norepinephrine, plasma glucose and cystatin C concentrations for up to 3 days after surgery. Etomidate successfully inhibited the cortisol response to surgery but plasma osteocalcin declined in all patients. This was accompanied by increased plasma catecholamines, interleukin-6 and glucose concentrations, and decreased cystatin C-values. Inhibition of the cortisol response to surgery failed to prevent a decrease in plasma osteocalcin concentrations after surgery, suggesting that other factors such as cytokines or catecholamines may play a significant role.     

腹腔镜治疗腹股沟疝临床疗效、胃肠动力和应激水平变化分析

目的探讨腹腔镜完全腹膜外疝修补术（laparoscopic totally extraperitoneal,TEP）治疗成人腹股沟疝患者临床疗效、胃肠动力和应激水平变化。 方法回顾性分析2012年1月至2017年6月,徐州市中医院普外科收治的成人腹股沟疝患者60例,随机数字表法分为试验组和对照组,每组患者30例,试验组给予TEP治疗,对照组给予开放式改良Kugel手术治疗,观察2组患者治疗后疗效、疼痛程度、并发症发生率、胃肠动力和应激水平变化。 结果试验组治疗后有效率（93.33%）高于对照组（63.33%）,VAS疼痛评分（3.21±0.96）和并发症发生率（16.67%）低于对照组（5.68±1.17,46.67%）,血清GAS、MTL、InS和GH水平均明显高于对照组,而血清β-EP、BS水平均明显低于对照组,差异均有统计学意义（P均<0.05）。 结论TEP治疗成人腹股沟疝患者具有良好的临床疗效,可有效改善患者胃肠动力和应激水平。